Inside Lacrosse January Issue: Q&A with Dr. Robert Cantu on Concussions in Lacrosse

Dr. Robert Cantu is one of the world's foremost experts on head injuries in sports. He's consulted or sat on boards for numerous bodies and leagues, notably the NFL and NOCSAE. His full resume can be seen here.

How familiar are you with men's and women's lacrosse?
My familiarity is that women need helmets and face shields and men have them and it’s a good thing they do.

Are helmets one of the primary actors in diminishing the amount of concussions in lacrosse?
I think you have to understand where concussions come from in girls’ lacrosse in order to understand my feeling about it. But first of all, generally speaking, helmets do not do a good job of preventing concussion when it’s primarily rotational forces from blows [a player's head] connecting with another head, or a knee or an elbow to a head, in which the head is spun on the neck such that the forces being imposed on the brain are rotational forces. As opposed to linear, or translational, forces, which are straight ahead in one direction. The reality is that the major cause of concussion is stick to the head. And I realize that’s not an intentional stick to the head, but that’s the reality. And helmets do a fantastic job of reducing what we refer to as focal forces — the types of forces that would be imparted by a stick crashing over the top of your head or hitting you in the face — things that would not spin your head but be a focal blow to the head. Therefore, understanding where the majority of concussions come form in women’s lacrosse makes me feel really strongly that head protection should be placed on the women, and obviously if there's head protection, then better face protection than the current could be affixed to the helmet.

Ivy League football contact is down from five days per week to two. The same commission has been charged to come up with ways to reducing head trauma in other sports at high risk like men’s and women’s lacrosse. These very things we’re talking about as it relates to lacrosse are being deliberated by that committee.

I fully understand the other side of the coin that if you put head protection on a sport that doesn’t have it, people will feel more invulnerable and the sport may get more dangerous because of risky behaviors. But in my opinion that’s where referees come in and have to be held accountable for officiating the sport appropriately. And quite frankly [referees in all sports] haven’t been held accountable in the past and they haven’t officiated appropriately, especially in football.

Because the NFL changed their rules to protect from head injuries, do you think lacrosse, aside from adding helmets on the women’s side, needs to adjust any rules to create the same protection?
I currently think the rules are quite good as they’re written. I think what isn’t good is that you don’t have head protection on these women and so when the rules are violated, they can receive a stick to the head, accidently or whatever.

I want to give you a philosophy, and part of it comes from my being involved as a ringside physician. If you think of the combat arts — ultimate fighting, boxing — the primary job of the referee in each of those sports is the safety of the combatants. That’s his primary job. In many states, that’s his only job, meaning he doesn’t score the bout — that’s done by others. That concept, I believe, needs to permeate collision sports. It’s interesting that 10 days ago [NFL Executive Vice President] Jeff Pash called me and asked my thoughts on empowering referees in the NFL to requites players that obviously appear impaired go to the sideline and get checked out before returning to play.

I told him in no uncertain terms, “Yes, I think it’d be extremely positive if the NFL would go on record as allowing referees in selected incidents where a player is grossly acting impaired to request he go to the sideline and be checked out.” Obviously, you can’t do it frequently throughout the game and it’d require training for the referees that don’t currently have it. But I think it’d be a huge step forward and I think that mindset should permeate other collision sports as well, like lacrosse, that one of [the refs'] responsibilities is to look out for the safety of the athlete.

Is lacrosse, due to its young stage of popularity, willingness to change and demographics of its participants, in a good place to be a leader in battling traumatic head injures in sports?
I think it’s uniquely positioned. Right now, there is of course professional lacrosse, but the majority of the players have day jobs. They love to play lacrosse professionally and they make money, but they don’t make big-time dollars that they can retire on, so there’s no way in the world they should be placing themselves at significant risk for lifelong problems after their career is over. And they’re nearly all college-educated individuals. So, with those two factors, I think lacrosse is uniquely positioned [to be a leader].

Where do you see the state of men’s field lacrosse helmets?
Not just lacrosse, but football and virtually all sports, is at the same level. We’ve done a great job of putting out standards and having manufacturers come up with materials that prevent against skull fracture and most inter-cranial hematomas. Subdurals are way low — very acceptable — we’d like them to be zero, but we’ll probably never get there, and skull fractures are way low. But quite frankly, we’re not there with regard to concussion and I don’t think helmets will ever be there 100% about concussions, but I think we can get a lot better. Having said that, the science isn’t known today exactly how to do that, so therefore I think there’s an urgent need to continue to do research to come up with more novel ways of attenuating the energies that happen when athletes receive blows to the head. And indirect blows that cause concussion due to whiplash effect — that’s probably never going to be eliminated by the helmet as it’s now constructed. But it could be if we figured out a way to make the helmet more affixed the shoulder pad by some type of collar that allowed you to still play the sport but decreased greatly the excursion of the head that can happen from indirect inertial loading that happen as the result of a blow to the back or the chest. Helmets have come a long way, but they have a long way to go. It’s not because NOCSAE doesn’t want them to get there, it’s because so far we haven’t seen the science that proves there’s a better mousetrap. But personally, I’m thrilled there’s so much interest in building a better mousetrap, because believe me it can get a lot better than it is. But it won’t get better with the materials and style that is currently used right now.

What are your thoughts on the Virginia Tech-Wake Forest School of Biomedical Engineering Star Rankings that evaluated football helmets in a new way? Do you think such a study would be valuable for lacrosse helmets?
I support the basic premise or concept of trying to see if one helmet is better than another. That’s a noble one. I’m supporting the concept. I believe you start doing that in the laboratory, but you don’t end up with it in the laboratory. You eventually have to go to the on-field, live time environment and see whether your lab theories hold up. I’d never want the laboratory to be the final source. The final source is “Does Helmet A protect better than Helmet B on the field?”

The problem is that particular way of testing has a lot of methodological flaws, so the very slight differences that were obtained leads me to believe you shouldn’t be giving someone a five-star and someone a four-star when the reality is so close.

What were some of the longterm goals I’d like to see put in place with regard to head injuries in sports?
I’d like to see rules that eliminate direct blows the head as being legal, I’d like to see equipment get better. I’d like to see the amount of head trauma ateetles receive in practice greatly diminish because, although the amount of head trauma that occurs in game play is roughly three times higher than in practice, because you spend so much more in practice the effect is much higher.

What we’re seeing in our study at the Center for the Study of Chronic Traumatic Encephalopathy at BU, we’re seeing that the athletes that end up with CTE seem to end up with it based on the total amount of brain trauma they sustain, not the amount of concussions. So we find athletes that have taken thousands of sub-concussive blows but only a few concussions might be at great risk than ateetles that have 10 or 11 recognized concussions but are playing a sport that is not at risk for repetitive head injury.

Does lacrosse have any profile in the Center?
We don’t have any cases of CTE in lacrosse. I’m sure it’s happened, but we don’t have it. I’d expect the incidence to be very low compared to football because there is not a fraction of the head trauma in lacrosse as happens in football. And I should say that the head trauma in men’s lacrosse that happens from sticks hitting off the helmet — the helmets do manage those very well.

Is lacrosse a wise choice for parents considering a sport for their son?
Yes, I think lacrosse is a great sport and a great option for kids. Personally, I think if a kid had to focus on a sport in the spring that lacrosse is a great one. The reality is that the same kind of kids that like to play football in the fall like to play lacrosse in the spring. If they start picking up concussions, we sit down with parents and, “If you’re child’s been fortunate enough to get over his most recent concussion and we can consider going back, you can’t keep exposing him to this type of trauma year-round. You have to pick one and, of the two, lacrosse would be the safer.”